Provider Demographics
NPI:1568576007
Name:THURSTON, CHARLES J (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:J
Last Name:THURSTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13316 MARIETTA RD
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:OH
Mailing Address - Zip Code:45644-9564
Mailing Address - Country:US
Mailing Address - Phone:740-701-1437
Mailing Address - Fax:740-655-2155
Practice Address - Street 1:13316 MARIETTA RD
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:OH
Practice Address - Zip Code:45644-9564
Practice Address - Country:US
Practice Address - Phone:740-655-2626
Practice Address - Fax:740-655-2155
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2017-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35043126207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0523599Medicaid
OH0523599Medicaid
OHTH4204788Medicare PIN